A friend who lives in Boston complained, not long ago, about not being able to find a physician. In Boston? “Come on,” I said. “This is like claiming you couldn’t find a liquor store.”
“They’re all oncologists and cardiologists,” he grumbled. “Last week I cut my hand badly enough that it needed stitches. I have good insurance. But I couldn’t get an appointment with my family doctor—or any of my friends’ doctors. I didn’t want to spend hours in the ER. So I wound up going to my sister’s house. She sewed it up at her kitchen table.”
His experience is not as unusual as it sounds. Some 56 million Americans do not have a regular source of care according to the National Association of Community Health Centers (NACHC) — even though many of them do have insurance. The problem is a shortage of primary care physicians (PCPs) in many parts of the country, particularly, but not exclusively, in poorer communities.
Even Docs Have to Call In Favors
Not long ago, Bob Wachter, Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco (UCSF) , and author of Wachter’s World warned his readers: “The Long-Awaited Crisis in Primary Care: It’s Heeere.”
Indeed, if you try get an appointment at UCSF’s general medicine practice, you will find that it is “closed” –even if you are an UCSF physician. They just aren’t taking any new patients. “Turns out we’re not alone,” Wachter adds. “Mass General also is not accepting any new primary care patients.”
He calls attention to “to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called ‘The Doctor Can’t See You Now,’ is the best reporting on this looming disaster I’ve heard .
Wachter summarizes highlights: “Getting a ‘regular doctor’ (a PCP) at Mass General now takes the combination of cajoling, pleading, and knowing somebody generally referred to as ‘working the system.’ In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant.
“The report also makes clear that providing more ‘access’ through expanded insurance coverage won’t do the trick,” Wachter explains. “Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.
“‘I received a card with my doctor’s name on it and I was told that
was my primary care physician,’ Jasbon recalls. “’I called the office.
They told me that they no longer took the insurance. So then I went
through every list of doctors in Sandwich, in the book, called each
doctor, and each doctor told me the new plan that I received, they, no
one took the insurance… I knew that there was something wrong with me,
and I was explaining to each doctor actually as I called them, "I’m
having problems urinating." Hot flushes, I was hot all the time. I knew
something was wrong, and I couldn’t get anybody to take care of me.’”
“Jasbon ended up in an ED [emergency department ], where he was
diagnosed with diabetes and hypertension. The ED staff helpfully
suggested that he should think about getting a PCP. . .”
Readers commenting on Wachter’s post confirmed the story. One wrote:
“I’m a physician and we moved to a new city a couple of years ago. I
had to twist arms and call in favors to get myself and my wife
PCPs–and we have ‘good’ insurance and no significant health problems
(yet).”
At the Center of Healthcare Reform: A Medical Home for Every American
In the meantime, health care reformers talk about how, once we have
national health insurance, we will create “medical homes” where
primary care physicians will, at last, be rewarded for taking the time
to co-ordinate patient care.
In a recent issue of the New England Journal of Medicine, for instance, a panel on “The Health of the Nation: Coverage for All Americans,” focused on the need for a “patient-centered home” that would be accountable for overseeing patient care.
The panel began by discussing the difficulties primary care
physicians face today. Dr. Arthur Caplan, a professor of bioethics at
the University of Pennsylvania, summed up the PCP’s lament: “I don’t
have time to talk to anybody . . . . I don’t get reimbursed enough. I’m
swamped by paperwork. I don’t have time for anything. And I answer to a
bunch of— non-MD folks who are telling me what to do half the time. . .
..”
By contrast, in the brave new world of universal coverage, the panel members agreed, primary care doctors should be rewarded for talking to their patients,
“making sure that patients are getting appropriate counseling” and that
“they’re up to date with their preventive care.” While specialists
may see only a single body part, the PCP will have “the big picture.”
Commonwealth Fund president Karen Davis explained how physicians
would be compensated: “in addition to fee for service [the practice
would receive] a monthly . . . fee for being a medical home. It’s a blended system of payment, which has worked very well in Denmark, where people have well-established relationships with primary care and compensation for primary care is on a par [with] or even higher than compensation for specialty care.
Former U.S. Senator Dr. Bill Frist then zeroed in on electronic
medical records, describing them as key to helping the primary care
doctor keep track of the specialists his patient is seeing, what those
doctors are prescribing, and what they are recommending.
Davis agreed: When it comes to healthcare information technology,
she noted, “we are way behind. One fourth of American primary care
physicians have electronic systems. The Netherlands, New Zealand,
Denmark, UK. . . ninety percent of physicians have totally electronic
offices. . . What’s different in those countries? The government was
willing to set standards on what is an acceptable system. . ..
And “in Denmark,” Davis added, “they found once they got this up and
running, they were saving 50 minutes a day. Because it was so much
easier to get the information they needed, to order a prescription or
authorize a refill of a prescription. It really pays off. . . . But it
needs leadership. National leadership…”
Others on the panel jumped into the conversation . . . . Until finally, Dr. Steven Schroeder a professor of health and health care at UCSF, interrupted:
“I think there is an elephant in the living room that we’re not
talking about. All these comments presume the persistence of a vibrant
primary care system.
“But,” Schroeder observed, “if [as we discussed earlier, doctors
are] telling their sons and daughters and nephews not to go into
medicine, those that [do] go into medicine know for sure they don’t
want to go into primary care. . . . They want to go on what they call
now the road to happiness. So this means they want to go into
Radiology, Ophthalmology, Anesthesia, Dermatology . . . It’s an
old-fashioned road. And why do they want to do that? They want to do
that because they’re coming out with huge debts. Because unless we fix
the payment system, they’re not gonna get the kind of income that
they’d like.”
But the problem isn’t just the relatively low pay that primary care
doctors receive. Students are also “more attracted to shift work, so
they don’t have to worry about patients after they leave,” Schroeder
added. “They want that eight-to-five job. And then finally, they don’t
like all the hassles that we’ve been hearing about” in primary care.
“So the electronic medical record by itself isn’t gonna fix that,”
Schroeder warned. “And unless we do more fundamental surgery on making
primary care a more compelling field…in the future in primary care
may will be practiced by [people] other than doctors. And maybe,”
Schroeder allowed, “this isn’t a bad thing…”
The discussion swirled forward, as panel discussions do, without
really facing up to the implications of Schroeder’s comment. But he
was asking exactly the right question about the promise of “a medical
home for every American.” Who, exactly, is going to be at home?
Once again, making sure that everyone has health insurance is not synonymous with ensuring that everyone has health care.
A Dearth of Doctors
Because the pay is low, the pace is hectic and the hours are long,
fewer and fewer medical students are becoming family doctors or
internists. Over the past decade, medical schools have witnessed a 22 percent drop in the share of graduates who choose to become “generalists”
rather than specialists. A 2008 NACHC study estimates that to provide
services to medically disenfranchised Americans who don’t have a
regular source of care, we would need up to 60,000 more primary care
professionals.
Instead, the pool is shrinking. Fed up with a broken system, older
PCPs are retiring early. And younger PCPs are switching specialties.
Wachter points to an “ABIM study [which] found that 10 years after
initial board certification, approximately 21% of general internists
were no longer in the practice of general medicine [vs. 5% of
subspecialists leaving their field].
“The dwindling number of PCPs who remain in practice are being far
more discriminating about the patients – and insurance payments – they
will accept,” Wachter adds. “With Medicare reimbursement tightening .
. . and Medicaid reimbursement near Starbucks barista levels . . . the
result is primary care ‘access’ that sounds good in a press conference
but is not real.
“You might ask, won’t the existing PCPs need to accept even these
low insurance payments? After all, they need to see some patients to
generate an income. Well, as it turns out, no,” writes Wachter,
answering his own question. “The remaining PCPs are in such demand .
. . that they can afford to limit their practice to patients with
better paying commercial insurance.”
In the NEJM panel discussion Schroeder suggested that “someone other
than doctors” may wind up doing the job. I’m assuming that he’s
referring to nurse practitioners. And certainly, nurse-practitioners,
working with primary care doctors, pediatricians or geriatricians
could screen patients, take care of the least complicated cases, and
give the doctor the 30 or 40 minute he needs to talk to—and listen
to—patients with more difficult problems.
But as Niko’s post below reveals, we also face a serious shortage of nurses. Indeed, the same 2008 NACHC study says that, in order to staff medical homes, we would need up to 44,500 additional nurses.
Boosting the pay for physicians and nurses willing to co-ordinate
patient seeing might draw more young professionals into primary care. But expanding the pool of primary care doctors and nurse is rather like drilling for oil.
Even if we raised their fees tomorrow, it would still take many years
for students to move through the pipeline, and into the workforce.
Moreover, it is important to keep in mind that it is not just the
low salaries that med students find daunting. “Some primary care
educators used to say that the problem was that students didn’t have
opportunities to see the real practice of primary care docs – if they
did, they’d recognize the subtle satisfactions and be more inclined to
enter the field,” Wachter notes. “But an upcoming paper by UCSF’s Karen
Hauer and others demonstrates that such exposure actually discourages
trainees from choosing primary care. Primary care docs are frustrated
and demoralized, and most of them are honest enough to share their
angst with their students. In other words, It’s The Practice, Stupid.
The Lack of PCPs Creates Holes in the System
In the meantime, as Kevin M.D. pointed out not long ago, the lack of primary care physicians helps explain the number of hospital re-admissions.
Kevin began by pointing to an op-ed in the Boston Globe which
urged Medicare to stop paying for patients who are rehospitalized
within 30 days after leaving the hospital. “These readmissions are
often avoidable,” the op-ed’s author wrote. “And if Congress focuses on
reducing the need for rehospitalization in areas where the practice is
most common, Medicare could save many billions of dollars.
Kevin took issue: “Not surprisingly, op-eds like these are written
by non-physician policy makers, and further puts doctors in
increasingly difficult situations. Physicians are pressured by
hospitals to discharge patients and keep the turnover high, which
increases revenue for the hospital. Now they’re taking it from the
other end, with this proposal not to pay for readmissions. It would be
nice if someone advocated the proper support system be put in place
first before acting on these ideas.
“The major reason for readmissions is inappropriate follow-up, which
can be directly traced to a lack of primary care access. Solve the
primary care shortage, and readmissions will go down.”
This makes sense. Granted, part of the problem is that some
hospitals don’t take enough time explaining medications to patients—and
making it clear what follow-up treatment they will need. But for proper
follow-up, patients do need that “medical home”—a primary care
physician who knows that his patient was in the hospital, and why, and
what the instructions are for follow-up care. The primary care doctor
should have the patient’s hospital records, a list of medications that
he is supposed to take, the dosages, and recommendations for physical
therapy or other treatments.
But if the patient does not have a primary care doctor, who is going to pick up the slack? The hospital can’t follow him home.
The lack of PCPs also is putting added stress on emergency care.
Patients who cannot get an appointment with a primary care doctor are
crowding ERS. From 1996 to 2006 Emergency room visits jumped more than
32 percent from 90.3 million according
to the National Center for Health Statistics, a division of the Centers
for Disease Control and Prevention. And this is not because more
Americans lack insurance.
To the contrary, the study found the proportion of emergency visits by the uninsured had not changed substantially between 1992 and 2005, although the number of overall visits went up 28 percent. The survey found that people in the highest income bracket – in excess of 400 percent of the federal poverty level — accounted for an increasing portion of emergency room visits, while the lowest income brackets remained virtually unchanged.
So much for the theory that illegal immigrants are responsible for the excruciatingly long waits in the nation’s ERs.
Who Suffers
“The state of primary care is not only sad, it is incredibly
stupid,” Wachter concludes. “ Mountains of research have demonstrated
that primary care-based care is less expensive – without access to
primary care doctors, patients get their basic care in emergency rooms,
or from subspecialists, or not at all. In any case, care is fragmented,
technology over-intensive, and wickedly expensive.”
Yet, “the forces of inertia getting in the way of solving the
primary care crisis are so strong that only a very powerful implosion
will create the political wherewithal to overcome them. Specialists
don’t want to forgo income, medical students will continue to vote with
their feet, existing primary care docs have resigned themselves to more
of the same and are hunkering down for retirement, and many patients are perfectly happy bypassing primary care docs to get their care from hordes of subspecialists.
The patients who take the biggest hit, of course, are poor and middle
class folks with chronic diseases – even those with insurance – who
can’t find a PCP and can’t afford a VIP doctor, and who therefore live
in perpetual fear of the next crisis.”
In Part II of this post, I’ll explore how specialists might become part of the solution. As Dartmouth researchers argue
in "Tracking the Care of Patients with Severe Chronic Illnesses:
Dartmouth Atlas of HealthCare 2008": “training more primary care
physicians alone won’t solve the problem of . . ..the lack of
co-ordination in our fragmented health care system.” If we want to
contain costs while lifting quality, specialists, too, will need to
begin thinking in terms of the “big picture.”
You need to remember PAs as well as NPs. PAs do not pull from the nursing work force like NPs do, thus exacerbating the shortage of nurses at the bed or chairside. While there are more NPs in the US than PAs, PAs statistically work more hours and see more patients and are more likely to be employed full time clinically. Just like the nursing workforce, many NPs have substantially scaled down or eliminated their clinical hours, and since the nursing shortage, many have gone back to working as RNs. About 50% of PAs work in primary care fields, and about 50% work in specialty areas. However, since they are all trained as generalists (unlike NPs, who are frequently trained only in specialty areas), PAs end up delivering quite a bit of primary care in specialty practices. And PAs are not pushing for independent practice and are quite willing to work in a physician captained team. Team medicine is their calling and specialty.
As one of those surviving PCPs, I marvel at all the discussion, but see little change in the near future. The medical home model is a demonstration project over 5 years. By that time, primary care will be dead and buried.
We saw the same inertia occur with the nursing shortage and little has changed to make nursing an appealing field. As always, the solution to these shortages is to open the doors to foreign medical graduates who take up the residency slots that American graduates won’t take and fill the nursing positions in hospitals and nursing homes, which has the effect of robbing third world countries of a valuable resource that they need even more than we do.
It all boils down to pay levels, but not in the absolute sense. What one needs to look at is the relative differences in pay levels between various occupations inside medicine (PCP vs. specialist) and vs those occupations outside of medicine. Also, the cultural acceptance of women working in professional occupations outside of those traditional tracks of elementary school teacher and nurse have dried up alot of the population willing to pursue these fields. I still do not see many male nurses filling the void where women once dominated. Now those women chose not to be nurses, but MDs, and look to occupations that will alllow them to raise families while they practice. This, I can tell you is not the lifestyle of a PCP.
My sense is the that it will take catactylsmic change to bring some balance to these issues. What we now have is many specialists and their specialty societies working very hard to maintain the status quo with the bulk of compensation and prestige flowing to these specialties. Hospitals are increasingly working towards maintainng the same since their reimbursement is most generous for specialty driven procedures and good primary care is actually not in their economic interest in the long term since it could actually decrease the need for these procedures and hospitilization. All this money translates into enormous influence at the govermental levels. As you have described previously in your blogs, this results in heavy influence on the committees governing physician payment and an unwillingness of our specialist breavren to give up one dime to increase primary care compensation if it means reducing their specialty compensation.
I sense that we are slowly walking down this path, which we have been for years, of an unsustainable system that. Before it is all over, we will have so depleted the resources of this country, that what we will have left will make us long for the good old days of medicine.
Pat & Keith–
Thanks for your comments.
Pat- What you say about Physician Assistants is interesting. Sounds like they should be a post . . .
Keith– Yes, I agree.
Inertia, combined with pressure from specialists who fear that if primary care physicians see raises, their fees will be cut, have slowed much-needed reform.
And when policy experts talk about medical homes, I do always wonder just who they think is going to staff them . . .
But in its most recent report, the Medicare Payment Advisory Commission talks paying some specialists (like those who specialize in diabetes)to create medical homes for patients–though they would have to meet stringent requirements like having electronic medical records, co-ordinating all of a patients care, and providing 24-acesss (something that only a multi-person practice could do.)
I can imagine a cardiologist also creating a medical home since many patients with heart problems essentially use their cardiologist as their primary care physician.
I’m wondering what other specialities might lend themselves to becoming medical homes?
Multi-speciality practices could become medical homes with the doctor who is the point person changing with the patient’s needs. For example, for a cancer patient her oncologist might become her medical home after the cancer is first diagnosed and while she is being treated. Then,
assuming her cancer went into remission, her family doctor would become her medical home–but if her cancer returned, her oncologist, who she had kept in touch with all along, would once again become her primary medical home.
Whether or not a specialist could provide a medical home depends on how much he knows about other parts of the body and whether he/she has the temperatment to co-ordinate,counsel the patient on preventive care, etc.
The specialist would be paid an extra flat fee
per patient per month for the time they spent consulting, co-ordinating etc.
At the same time, the specialist might well find his fees for certain procedures and tests cut as Medicare reviews its fee for service schedule (and insurers follow suit.)
Bottom line: primary care docs other generalists (pediatricians, family docs, geriatricians) would be paid more for providing a medical home; some specialists also would be paid for providing a medical home and less for procedures, so that the source of their income would shift as we begin to pay more for cognitive medicine, less for procedures; some specialists would see fees cut without a concomitant increase for cognitive medicine because they’re really not in a position to provide a medical “home.”
Pat & Keith–
Thanks for your comments.
Pat- What you say about Physician Assistants is interesting. Sounds like they should be a post . . .
Keith– Yes, I agree.
Inertia, combined with pressure from specialists who fear that if primary care physicians see raises, their fees will be cut, have slowed much-needed reform.
And when policy experts talk about medical homes, I do always wonder just who they think is going to staff them . . .
But in its most recent report, the Medicare Payment Advisory Commission talks paying some specialists (like those who specialize in diabetes)to create medical homes for patients–though they would have to meet stringent requirements like having electronic medical records, co-ordinating all of a patients care, and providing 24-acesss (something that only a multi-person practice could do.)
I can imagine a cardiologist also creating a medical home since many patients with heart problems essentially use their cardiologist as their primary care physician.
I’m wondering what other specialities might lend themselves to becoming medical homes?
Multi-speciality practices could become medical homes with the doctor who is the point person changing with the patient’s needs. For example, for a cancer patient her oncologist might become her medical home after the cancer is first diagnosed and while she is being treated. Then,
assuming her cancer went into remission, her family doctor would become her medical home–but if her cancer returned, her oncologist, who she had kept in touch with all along, would once again become her primary medical home.
Whether or not a specialist could provide a medical home depends on how much he knows about other parts of the body and whether he/she has the temperatment to co-ordinate,counsel the patient on preventive care, etc.
The specialist would be paid an extra flat fee
per patient per month for the time they spent consulting, co-ordinating etc.
At the same time, the specialist might well find his fees for certain procedures and tests cut as Medicare reviews its fee for service schedule (and insurers follow suit.)
Bottom line: primary care docs other generalists (pediatricians, family docs, geriatricians) would be paid more for providing a medical home; some specialists also would be paid for providing a medical home and less for procedures, so that the source of their income would shift as we begin to pay more for cognitive medicine, less for procedures; some specialists would see fees cut without a concomitant increase for cognitive medicine because they’re really not in a position to provide a medical “home.”
Maggie – Family Medicine, Family Practice, or a General Internal Medicine service are such low priorities in most academic medicine centers’ (AMCs) its almost miraculous that the faculty tolerate their appearance in org charts.
The well documented patient care vs. research and teaching mission tensions at AMC’s tend to squarely place direct “patient care” in a low priority position. Incentives and culture clearly favor first research and publishing, second is the teaching drive, and seeing patients, well – OK, if we have too. If it weren’t for the shaky financial condition of most AMC’s, the reliance on patient care revenue would not even register as an institutional priority, IMO.
And this is before discussion of the role of PCPs in patient “load balancing” – if you will.
Maggie,
Your posting is getting to the “real heart” of the problem that Massachusetts and the country are facing, that of access to and utilization of care. The problem is more complicated then just shortages of this or that physician specialty or this or that insurance. Massachusetts has the highest number of primary care physicians in the US except Washington D.C. yet rank near the top of ER visits per capita. Washington D.C. has the highest ER utilization rate in the country. There is no correlation between a states per capita number of primary care physicians and ER utilization. The reasons for the present physician situation in US are multi factorial and money is the least of them (more than 1/3 of all family physician and general internists earn > $200,000/yr. and that’s with over all productivity dropping). When Congressed passed the 1996 Balanced Budget Act there was a tremendous drop off in the numbers of primary care residency slots being filled. Calculations for physician workforce requirements at the time used a cost affordable method saying the demand or needs formula wasn’t necessary because all disease didn’t have to be treated. The only problem is they didn’t tell the public which diseases did not require treatment. Medicaid recipients and the uninsured only received 2/3 of the FTEs that those with Medicare and those with private insurance received. The present system capacity was planned this way and it will get worse. None of the health care reform plans proposed take system capacity into account or address patient behavior. (It’s why I faxed NAEHC). Patient behavior is just as important if not more so than physician access. I’m not just talking about obesity, smoking or wearing your seat belt but about how patients interact with the health care system and “their” disease. Patient non-compliance, their inability to utilize or lack of desire to utilize the health care system properly for “their” benefit dwarfs all other reasons for health care costs (1 out of 10 hospital admissions and excess of $300 billion dollars per year in costs) and an estimated 124,000 deaths per year (6x what the estimates are for deaths due to lack of insurance).Until we realize that insurance is not access (sometimes access is not access) and patients realize they are not consumers but their most important providers we are never going to get a grasp on costs or outcomes.
“I can imagine a cardiologist also creating a medical home since many patients with heart problems essentially use their cardiologist as their primary care physician.”
This is exactly what I do, and it works very well. My cardiologist is also the PCP who does our corporate physicals which is how I met him in the first place. I also agree that diabetes specialists as well as oncologists can provide medical homes. Beyond that, NP’s and PA’s can be much more fully utilized than they currently are to provide primary care for those cases that are within their capability to handle. Insurance company nurse hotlines, aided by computerized decision support tools, can also be helpful when a patient’s regular doctor is not available. I have personally used this service twice in the last six months and was well satisfied with the advice and guidance I received. One of those instances occurred while I was on vacation more than 2,000 miles from home. This service could become even more valuable and useful as video communication technology advances and prices fall to a level that most people can afford.
One lesson I’ve learned over and over during the last 35 years is that our economic system is resilient and innovative. Numerous jobs have been deskilled over the years thanks to technological advances. I don’t think the nurse hotlines would be nearly as useful, for example, without the computer based decision support tools.
Ironically, I think what PCP’s should be rooting for is a shift in the payment system away from fee for service and toward capitation supplemented by significant advances in the ability to create medical risk scores at the individual level that would help insurers, doctors, and hospitals to better estimate the likely healthcare costs of the population they serve. With capitation, both hospitals and doctors would suddenly find that they make more money if they succeed in keeping patients healthy. While adequate safeguards will be needed to make sure that patients are not deliberately under treated to save money, I think a fundamental change in the payment model away from fee for service and toward capitation is the way we need to go.
Gregg,James and Barry
Good to hear from you–
Gregg–When I ask physicians in N.Y. about hospitals in Manhattan I’ve been told that most are “reserach oriented.” Patient care really is not their main concern. That’s not where the money is– or the glory.
James—Thanks.
It is becoming more and more apparent to me that making sure that everyone has health insurance is not the answer to our healh care crisis.
If everyone had equal coverage–covering everything you and I would want for our families–and if doctors were paid the same fees when caring for all of us (no low fees for Medicaid patients etc.)
that might be a beginning.
But the problem is that even if you have good insurance, that does not assure good care. We need to change the financial incentives, and redistribute health care dollars to reward more preventive and cognitive medicine and much less in the way of bleeding-edge, not entirely proven procedures.
As for the problem of patients failing to utilize the system–I have to say that, given the state of the system, even some doctors I know say that whenever possible, you want to keep a healthy distance between you and our heatlh care system.
Of course if you’re pregant, you need regular check-ups. If you’re a diabetic, have glaucoma, heart disease etc., you need to keep on top of it.
But if at all possible, you want to avoid hospitals, tests that will lead to other tests etc.
I feel much more comfortable with pretty conservative doctors . .
Barry–
Yes, I thought you had mentioned that your cardiologist is your main doctor. And I have one other friend who has always used his cardiologist as his primary.
I can definitely see this working out. I wonder how many specialits would want to (and would have the skills and knowledge to) bcome generalists, providing medical homes, if they were paid for their time?
Their total income probably wouldn’t be as high as it is now (certainly not if we’re talking about the highest-paid specialties where people are making $650,000 and more) But some
might find it very satisfying in a different way. I do know that, after a period of years some specialists become burned out in (or even bored with) their specialty.
Perhaps I’m day-dreaming. I would be interested in what doctors have to say.
I wonder if some proceduralists would have want to do some re-training to move into
cognitive medicine . . .
Acess and manpower issues in healthcare! Good subjects to bring up, finally. System oriented success questions:
Will Americans accept queues for equal fairness on the access side??
Will more providers be allowed to exist to minimize queing??
Can evidenced-based medicine along with more “good-health” oriented directed financial incentives be able to allow fairness of access with minimal ques??
Finally, do not stop at just nurses and PCP!! Dentists will be in great shortage with or without universal dental coverage as is happening even now!
Primary care
Must-read piece from Maggie Mahar, explaining the implications and causes of the primary care shortage. Many points are familiar to readers of this blog, but here are a few that I’d like to underline.
i) Some physicians (invariably naive academics) feel
What is the problem: Healthcare coverage or PCP shortage?
The political atmosphere fueled by the public’s continued frustration keeps healthcare issues in the forefront. Is insurance coverage, universal or otherwise, the real issue that will cure the “healthcare crisis” in America? A recent piece wri
Maggie,
I agree with your conservative position in seeking health care, but I do hope you are performing your preventative screenings and health services. I detect a note of distrust in the current providing system. If you don’t have faith in your providers, find new ones and keep searching until you do. Most people don’t have that luxury or the means to carry it out. It would be beneficial to see a posting on the magnitude of healthcare consumer non-compliance and its effect on the various reform plans including both payment reform and delivery reform models. The effect of system capacity on each plan would be beneficial to those who will decide which way we are going to go. Until both of these areas are addressed in any proposed reform we are just fooling ourselves. Again, keep up the good work.
re Primary Care
“availability”
I have good care
because I have a
disease that needs
the regular attention of a specialist. But my high quality primary care is of little use at all,
That fancy office is run like a factory, and communication
is the last thing
on anyone’s mind.
ray karel
Maggie,
I am a practicing internist and in the past have taught house staff for 30 years. The collapse of primary care was not inevitable. It was caused by the policies of managed care. Managed care in turn implements the rules of the Federal Trade Commission-the real and overlooked culprit in this matter. I wrote a recent article on this subject that appeared in Missouri Medicine. If you or anyone else would like to have it, I will email or fax a copy to you. My email is agalemd@aol.com.
Arthur Gale MD
NG, James MD, Ray and Arthur . .
NG – You ask: “Will Americans accept queues for equal fairness on the access side?”
I think they should– as long as we’re talking about elective, non-emergency procedures.
Waiting 6 or 8 weeks for your artifiical knee implant is not a terrible thing. In fact, research shows that if patients have more time to think about and learn about the risks and benefits of elective surgery, about 20 percent will decide not to do it. (See what I’ve written about “shared decision-making).
In this country, we tend to be in a rush–and rushing into operations is generally not a good idea.
Often, it’s better to try a more conservative approach first–physical therapy for the knee, a change of diet and exercise (rather than angioplasty) for the angina, etc.
Ray– I do think that someone with a chronic condition that needs regular attention can find a good medical home with a specialist–as long as the
specialist is willing to take on that respnsibility.
Now we just have to adjust fee schedules to pay specailist for the time it takes to co-ordinate and oversee a patient’s care. And cut fees for some less effective procedures–shifting the specialist’s income toward more cognitive medicine.
jamesd– Thanks
I do believe in treating what can be treated.
For instance, I have a very good eye doctor; I have glaucoma and have to keep an eye on it. I’m lucky–by adjusting the eye drops, we can keep the pressure down. I do need to see him every three months–but this is a disease we know how to treat.
I also have a gynecologist.
On the other hand, I don’t go for annual physicals because I don’t really have any symptoms–and without symptoms, it seems a fishing expedition. One test can too easily lead to another. . .unncessary worry, unnecessary procedures.
But I do have an appt. with a new, highly-recommended primary care physician.
It’s become very hard to find a PCP in Manhattan, so I’m going to this person even though she doesn’t take my insurance I want to have someone to call in case of a real problem.
Right now, I simply want a prescription for some physical therapy.(In NYS you can’t go for physical therapy without a prescription from an M.D.–which seems to me foolish.Therapists shoudl be licensed, and regulated, but since my M.D. doesn’t know the therapist, having him/her
write a prescription really doesn’t protect me.
As a writer, I spend way too much time sitting, and I have found that physical therapy can really loosen me up–and then it’s much easier to exercise. (Everyone–if you can find a good therapist, I highly recommend it.)
Arthur– Managed care would be a good idea– if we “managed” care by looking at what works and what doesn’t–paying for effective care and refusing to cover ineffective care.
We do need evidence-based guidelines–there is way to much variation in medical care in this country.
But unfortunately, too many for-profit insurers were “manging care” by looking att he price, not the quality of the care.
They weren’t managing care, they were managing money.
I am a General Internist (now called a primary care physician) and I have watched and experienced the slow death of the PCP over the past 15 years. With only 2% of all medical students choosing primary care specialties we are fiddling while Rome burns. The medical home as currently proposed is an unworkable solution because it requires resources that only large medical groups can provide. It is yet another way to waste time fiddling around the edges instead of committing to real reform. Increase pay (by a lot!) and you will start restoring interest in primary care. Primary Care doctors need more time to care for patients, to think, to consult and to do health outcomes research. Pay for thinking not just cutting. Stop over paying hospitals and specialists for procedures that have no proven benefit. Get rid of the secretive RUC…made up of specialists who are only protecting their own overinflated incomes. Every developed country with better health outcomes (except Cancer) than the U.S. invests in primary care for the health of the nation. The U.S. has no real policy except lobbying and greed. I believe Universal care is the primary need of this nation but without addressing the primary care inequities you are correct…No-one at home.
The crisis we face as baby boomers will not be primarily financial — it will be a crisis in the availability and supply of medical care resources — everything from primary care physicians to long term alzheimer’s facilities. Some day we have to pull our heads out of the collective sand and face these issues, and do something about them.
areas. However, since they are all trained as generalists (unlike NPs, who are frequently trained only in specialty areas), PAs end up delivering quite a bit of primary care in specialty practices. And PAs are not pushing for independent practice and are quite willing to work in a physician captained team. Team medicine is their
Health Care has been a big concern for every one these days.
It’s so sad that even when you have good insurance, for which you pay quite a lot, you still can get awfully bad treatment.